During triage, the nurse should check first which client?

• A. Client with dehydration.
• B. Client with history of partial seizures who is picking at clothing and lip smacking.
• C. Client with a headache.
• D. Client who is asleep.

Answer: (B)

In triage, the first priority is any situation that could compromise airway, breathing, or circulation. The client who has a history of partial seizures and is picking at clothing and lip smacking is showing automatisms consistent with ongoing seizure activity. Active seizures pose a high risk of airway obstruction, hypoxia, injury, and, if they continue, progression to status epilepticus, which is life-threatening. Because of that immediate danger, this client must be assessed and managed right away to ensure the airway is protected, monitor breathing, and prepare for urgent intervention if the seizure persists.

The other scenarios, while important, do not present the same immediate risk. Dehydration can progress to shock if severe, but it typically progresses more slowly than an ongoing seizure. A headache is common and often non-emergent unless accompanied by red flags. A client who is asleep may require reassessment, but there is no active threat of airway compromise unless the patient is unresponsive or not breathing adequately.